- The Lancet

Genetic diagnosis of developmental disorders in the
DDD study: a scalable analysis of genome-wide research data
Caroline F Wright, Tomas W Fitzgerald, Wendy D Jones, Stephen Clayton, Jeremy F McRae, Margriet van Kogelenberg, Daniel A King,
Kirsty Ambridge, Daniel M Barrett, Tanya Bayzetinova, A Paul Bevan, Eugene Bragin, Eleni A Chatzimichali, Susan Gribble, Philip Jones,
Netravathi Krishnappa, Laura E Mason, Ray Miller, Katherine I Morley, Vijaya Parthiban, Elena Prigmore, Diana Rajan, Alejandro Sifrim,
G Jawahar Swaminathan, Adrian R Tivey, Anna Middleton, Michael Parker, Nigel P Carter, Jeffrey C Barrett, Matthew E Hurles, David R FitzPatrick,
Helen V Firth, on behalf of the DDD study*
Background Human genome sequencing has transformed our understanding of genomic variation and its relevance
to health and disease, and is now starting to enter clinical practice for the diagnosis of rare diseases. The question of
whether and how some categories of genomic findings should be shared with individual research participants is
currently a topic of international debate, and development of robust analytical workflows to identify and communicate
clinically relevant variants is paramount.
Published Online
December 17, 2014
Methods The Deciphering Developmental Disorders (DDD) study has developed a UK-wide patient recruitment
network involving over 180 clinicians across all 24 regional genetics services, and has performed genome-wide
microarray and whole exome sequencing on children with undiagnosed developmental disorders and their parents.
After data analysis, pertinent genomic variants were returned to individual research participants via their local clinical
genetics team.
See Online/Correspondence
Findings Around 80 000 genomic variants were identified from exome sequencing and microarray analysis in each
individual, of which on average 400 were rare and predicted to be protein altering. By focusing only on de novo and
segregating variants in known developmental disorder genes, we achieved a diagnostic yield of 27% among
1133 previously investigated yet undiagnosed children with developmental disorders, whilst minimising incidental
findings. In families with developmentally normal parents, whole exome sequencing of the child and both parents
resulted in a 10-fold reduction in the number of potential causal variants that needed clinical evaluation compared to
sequencing only the child. Most diagnostic variants identified in known genes were novel and not present in current
databases of known disease variation.
Interpretation Implementation of a robust translational genomics workflow is achievable within a large-scale rare
disease research study to allow feedback of potentially diagnostic findings to clinicians and research participants.
Systematic recording of relevant clinical data, curation of a gene–phenotype knowledge base, and development of
clinical decision support software are needed in addition to automated exclusion of almost all variants, which is
crucial for scalable prioritisation and review of possible diagnostic variants. However, the resource requirements of
development and maintenance of a clinical reporting system within a research setting are substantial.
Funding Health Innovation Challenge Fund, a parallel funding partnership between the Wellcome Trust and the UK
Department of Health.
Copyright © Wright et al. Open Access article distributed under the terms of CC BY.
The increasing use of whole exome and whole genome
sequencing in both research1,2 and clinical practice3–5 raises
questions about how to maximise the diagnostic
usefulness of genomic data and how to share results with
research participants and patients. Furthermore, it is
increasingly deemed ethically desirable to return clinically
useful results to research participants.6 However, return of
individual genomic results poses major logistical
challenges. A robust workflow must be developed to track
individual samples and datasets, generate high-quality
genomic data, filter out a very large number of probably
benign variants, prioritise plausibly pathogenic variants,
and link these findings to individual clinical data for
interpretation and appropriate clinical follow-up.
Health-related findings from a human genome could
potentially include thousands of variants pertaining to
hundreds of different conditions,7 almost none of which
provide clinically useful information for a specific
individual.8 A first step toward addressing these challenges
is to separate potential genomic findings into those that
are pertinent to a particular disease investigation and
those that are non-pertinent (or incidental) to that disease.
Although many commentators have debated the merits of
returning different classes of findings from large research
studies and biobanks,6,9,10 none has yet provided a scalable
www.thelancet.com Published online December 17, 2014 http://dx.doi.org/10.1016/S0140-6736(14)61705-0
See Online/Comment
*Listed in appendix 1
Wellcome Trust Sanger
Institute, Wellcome Trust
Genome Campus, Cambridge,
UK (C F Wright PhD,
T W Fitzgerald MS,
W D Jones MBBS,
S Clayton MRes, J F McRae PhD,
M van Kogelenberg PhD,
D A King MD, K Ambridge BSc,
D M Barrett BSc,
T Bayzetinova BSc,
A P Bevan PhD, E Bragin MSc,
E A Chatzimichali PhD,
S Gribble PhD, P Jones MSc,
N Krishnappa MSc,
L E Mason BSc, R Miller PhD,
K I Morley PhD,
V Parthiban PhD,
E Prigmore PhD, D Rajan MSc,
A Sifrim PhD,
G J Swaminathan PhD,
A R Tivey MSc,
A Middleton PhD,
N P Carter PhD, J C Barrett PhD,
M E Hurles PhD, H V Firth DM);
Institute of Psychiatry, King’s
College London, London, UK
(K I Morley); Melbourne School
of Population and Global
Health, The University of
Melbourne, Melbourne, VIC,
Australia (K I Morley); The
Ethox Centre, Nuffield
Department of Population
Health University of Oxford,
Old Road Campus, Oxford, UK
(Prof M Parker PhD); MRC
Human Genetics Unit, MRC
IGMM, University of
Edinburgh, WGH, Edinburgh,
UK (Prof D R FitzPatrick DM);
and Cambridge University
Hospitals Foundation Trust,
Addenbrooke’s Hospital,
Cambridge, UK (H V Firth)
Correspondence to:
Dr Caroline F Wright, Wellcome
Trust Sanger Institute, Wellcome
Trust Genome Campus, Hinxton,
Cambridge CB10 1SA, UK
[email protected]
See Online for appendix 1
For more on the DDD study see
For the DECIPHER database see
implementation from patient identification through to a
confirmed diagnosis within a research context. Here we
describe the development and implementation of a
translational genomics workflow in a large-scale rare
disease research study to communicate pertinent findings
to individual research participants, whilst minimising
incidental findings.
The Deciphering Developmental Disorders (DDD)
study11 is a UK-wide collaborative project that seeks to
facilitate the translation of genomic sequencing
technologies into the National Health Service (NHS), by
collecting a set of high-resolution genomic and phenotypic
data for children with severe undiagnosed developmental
disorders and their parents. Although whole genome
microarray analysis has already proven invaluable
for identification of large pathogenic copy number
variants (mostly deletions and duplications) in children
with developmental disorders,12 most children remain
undiagnosed. In many cases, the condition is caused by
a de novo mutation that occurs spontaneously in the
affected child somewhere in the genome,13–15 and if there is
no family history of the condition the genetic basis of the
diagnosis can be easily overlooked. The recruitment
criteria for the study are focused on congenital or early
onset severe phenotypes, and were specifically designed to
maximise the chance of finding a highly penetrant
monogenic cause for the child’s condition. The study was
established with the dual aim of assisting the translation
of new high-throughput genomic technologies into
clinical practice, and elucidating the underlying genetic
architecture of developmental disorders. Cambridge
South Research Ethics Committee (REC) approved the
feedback of potentially causal variants from DDD to the
patients’ regional genetics centre, whose responsibility it
is to assess and validate the findings before communicating
them to the families with appropriate counselling
regarding recurrence risk, likely prognosis, and potential
clinical management. The judgment not to feed back
incidental findings was REC-approved, and the protocol
and patient information sheets clearly state that “incidental
findings will not be reported back in the DDD study”.
Nonetheless, we developed a parallel research study to
investigate attitudes towards feeding back a broader range
of genomic results to research participants.16,17
We outline a process to identify and report likely causal
variants (pertinent findings) in individual patients, and
summarise the results to date. There are many different
classes of disease-causing genetic variation, of which
some are observed infrequently (eg, uniparental disomy,
in which both copies of a single chromosome are
inherited from one parent, which occurs in fewer than
one in 1000 individuals18), whereas others are observed in
huge numbers (eg, single DNA base changes, of which
every individual has millions in their genome). Different
genetic changes need different analysis methods; in
particular, more numerous forms of genetic variation
need a scalable automated approach. We describe the
workflow we have developed to achieve a scalable
genome-wide diagnostic analysis, focusing particularly
on the automated part of a larger workflow, and we show
the clinical usefulness of this workflow using data for
1133 probands with severe undiagnosed developmental
disorders as an example.
Clinical data collection
Patient recruitment
Clinical data
Genomic data
Family history
SNVs, indels, CNVs
UPD, mosaicism
Automated variant
(1) annotation
(2) filtering
(3) prioritisation
Selective variant
Manual review
Diagnostic confirmation and families informed
Figure 1: Study workflow
SNV=single nucleotide variant. Indel=insertion or deletion. CNV=copy number variant. UPD=uniparental disomy.
We developed a workflow to facilitate patient recruitment,
sample tracking, data generation, data analysis, variant
filtering, manual curation, and feedback of results
(figure 1; appendix 1). Clinically ascertained undiagnosed
patients meeting the recruitment criteria (severe
undiagnosed neurodevelopmental disorder and/or
congenital anomalies, abnormal growth parameters,
dysmorphic features, and unusual behavioural phenotypes) were recruited to the DDD study by their UK NHS
or Irish Regional Genetics Service, who also recorded
clinical information and phenotypes using the Human
Phenotype Ontology (HPO)19 via a secure web portal
within the DECIPHER database.20 A team of research
coordinators (typically research nurses and genetic
counsellors) working in each of the regional services
provided essential support with informed consent,
sample collection, and data entry (antenatal and growth
data, developmental milestones, family history, previous
genetic testing, etc) with the patient’s phenotype being
entered by their clinical geneticist. The study has UK
Research Ethics Committee approval (10/H0305/83,
granted by the Cambridge South REC, and GEN/284/12
granted by the Republic of Ireland REC).
www.thelancet.com Published online December 17, 2014 http://dx.doi.org/10.1016/S0140-6736(14)61705-0
Genomic assays
Saliva samples from patients and their parents were
collected (Oragene DNA collection kits, DNA Genotek,
blood-derived DNA from the child was also provided by
MAF ≤1%; CNV overlap
with common CNV ≤80%? Yes
Protein altering, LOF,
change in gene dosage? Yes
the regional genetics laboratories. DNA samples from
patients and their parents were analysed at the
Wellcome Trust Sanger Institute with microarray
analysis (Agilent 2x1M array CGH [Santa Clara, CA,
USA] and Illumina 800K SNP genotyping [San Diego,
CA, USA]) to identify copy number variants (CNVs) in
Dominant DDG2P
gene overlap?
Variant type
Phenotype match?
De novo?
Inherited from
affected parent(s)?
Recessive DDG2P gene
(X only)
Inheritance unknown?
Manual review meeting
De novo?
Inherited from
affected parent(s)?
Inherited from
unaffected parent(s)
heterozygous at site?
Non-DDG2P gene
>500 kb?
>250 kb gain or
>100 kb loss?
Data quality
De novo?
Inherited from
affected parent(s)?
Figure 2: Variant filtering logic for clinical reporting within the study
Genomic variants were filtered on the basis of six factors, of which the first five were automated and the final one was done manually: (1) frequency, prevalence of the variant in the general population (MAF
≤1%); (2) function, most severe predicted functional consequence, such as LOF, defined by specific sequence ontology terms (transcript ablation, splice donor variant, splice acceptor variant, stop-gained,
frameshift variant, stop-lost, initiator codon variant, in-frame insertion, in-frame deletion, missense variant, transcript amplification, and coding sequence variant); (3) location, genomic location compared
with DDG2P of published genes; (4) variant type, genotype (eg, heterozygous or homozygous) and loss or gain for small CNVs (which were only considered when they contained entire genes in which LOF
or dominant negative mutations had been previously reported, and gains were only considered when they overlapped genes in which increased gene dosage mutations had been previously reported); (5)
inheritance, aspects of the pipeline that are dependent on inheritance information derived from parental data are shaded; and (6) phenotype, patient phenotype was manually compared against published
phenotypes for a particular gene. MAF=minor allele frequency. CNV=copy number variant. LOF=loss of function. DDG2P=Developmental Disorders Genotype-to-Phenotype database.
www.thelancet.com Published online December 17, 2014 http://dx.doi.org/10.1016/S0140-6736(14)61705-0
the child, and exome sequencing (Agilent SureSelect
55MB Exome Plus with Illumina HiSeq) to investigate
single nucleotide variants (SNVs), small insertiondeletions (indels), and CNVs in coding regions of the
genome (appendix 1). Putative de novo sequence
variants identified using DeNovoGear21 were validated
with targeted Sanger sequencing. The population
prevalence (minor allele frequency) of each variant in
nearly 15 000 samples from diverse populations was
recorded, and the effect of each genomic variant was
predicted with the Ensembl Variant Effect Predictor
(VEP version 2.6)22 (appendix 1).
Variant filtering
For the European GenomePhenome Archive see www.ebi.
See Online for appendix 2
An automated variant filtering pipeline was used to
narrow down the number of putative diagnostic variants
(figure 2). First, common (>1% minor allele frequency)
and non-functional (not protein-altering) variants were
filtered out. Second, potentially pathogenic variants in
known disease genes were selected in by comparison
against an in-house database of genes consistently
implicated in specific developmental disorders, the
Developmental Disorders Genotype-to-Phenotype database (DDG2P). This database includes more than
1000 genes that have been consistently implicated in
specific developmental disorders and is updated regularly
with newly implicated genes (table 1; appendix 1;
appendix 2). Each gene in DDG2P is associated with a
specific developmental phenotype or syndrome via a
particular genetic mechanism (autosomal dominant,
autosomal recessive, or X-linked) and mutation
consequence on the gene product (loss of function,
activating mutation, increased gene dosage, etc). The use
of DDG2P enabled any rare variant in a known DD gene
with a predictable effect on the gene product to be flagged
on the basis of inheritance, genotype, and likely
mutational consequence. Large, rare CNVs overlapping
non-DDG2P genes were also flagged based on a series of
size thresholds (>100 kb for losses and >250 kb for gains
where the inheritance was either de novo or segregated
with disease, and >500 kb for any genic CNV for which
the inheritance was unclear).
Total reportable genes* 819
November, July,
Genes added
Genes removed†
In addition to genes being added or removed, annotations for existing genes can
also change (eg, to include multiple modes or mechanisms). The November, 2013
version was used for the analysis presented here and includes 1128 reportable genes.
DDG2P=Developmental Disorders Genotype-to-Phenotype database. *DDG2P also
contains non-reportable categories when there is insufficient evidence associating a
gene and developmental disorder (appendix 1). †The selection of variants for
reporting is based on the strongest available evidence of gene function and no
variants yet reported have been retracted because of changes in the DDG2P list.
Table 1: Changes to DDG2P over time
Sharing of results
Flagged variants were manually reviewed in a weekly
multidisciplinary team meeting including clinical
geneticists and genetic scientists to assess their
analytical and clinical validity. Patients’ detailed clinical
presentation and family history were compared against
published clinical features for each gene containing
flagged variants, to evaluate the likely relevance in
that specific patient. When there were sufficiently
overlapping clinical features, the variant (chromosome,
position, gene[s], allele, genotype, inheritance, and
most severe predicted consequence) was approved for
reporting to the regional genetics service via the
patient’s referring clinician. Variants were deposited
into the patient’s record via the secure study web
portal DECIPHER, where they could be viewed in an
interactive genome browser to enable local evaluation,
diagnostic laboratory validation, and discussion with
the family as appropriate. Anonymised variants were
made publicly accessible after a short holding period (to
ensure the opportunity for families to be informed
before release). Full genomic datasets were also
deposited in the European Genome-Phenome Archive
in accordance with the REC approval for the study.
Role of the funding source
The funders of the study did not contribute to the study
design, data collection, data analysis, data interpretation,
report writing, or the decision to submit this paper for
publication. The corresponding author had full access to
all the data in the study and final responsibility for the
decision to submit for publication.
To achieve equity of access for all undiagnosed families
with developmental disorders in the British Isles, every
UK NHS regional genetics service was involved
in supporting and setting up the study; Ireland was
subsequently added after the study had started. Almost
all consultant clinical geneticists (more than 180) across
all 24 regional genetics services in the UK and Ireland
have recruited families to the DDD study, with the help
of local research coordinators (typically research nurses
or genetic counsellors). Around 2000 families were
recruited in the first year of the study, rising to more
than 8000 within 3 years. Among the first 1133 complete
family trios (child, mother, and father), the male-to-female
ratio among the probands was 51:49 and the median age
at last clinical assessment was 5·5 years (SD 4·0, range
0–16). 121 (11%) children had one parent affected with a
(typically milder) developmental phenotype, and 23 (2%)
had both parents affected with developmental phenotypes
(most often mild intellectual disability). Before entering
DDD, 868 (77%) of the cohort had received clinical
microarray testing, 633 (56%) had at least one targeted
genetic test, and 522 (46%) had received both. Across the
cohort, 1435 unique phenotype terms of the roughly
www.thelancet.com Published online December 17, 2014 http://dx.doi.org/10.1016/S0140-6736(14)61705-0
Seizures (24%)
Intellectual disability or
developmental delay (87%)
Proband only
Family trios
Autism spectrum disorder (10%)
Hearing impairment (7%)
Oral cleft (6%)
Congenital heart
defects (11%)
Scoliosis (5%)
Number of probands
Visual impairment (3%)
Polydactyly (1%)
Number of flagged variants per child
(compound heterozygotes counted once)
10 000 available in the HPO were used to describe clinical
presentations, with a mode of 4 per proband (range 1–27);
987 (87%) children had intellectual disability, 270 (24%)
had a history of seizures, and 121 (11%) had a congenital
heart defect (figure 3).
Around 80 000 genomic variants were identified from
exome sequencing and array comparative genomic
hybridisation in each individual proband, of which on
average 400 were rare and protein altering, and
30 of these overlapped known DDG2P genes. Further
filtering based on DDG2P categories resulted in a
median of 10 flagged SNVs and indels per proband in
the absence of parental data (range 2–25). We further
refined this to a median of 1 per proband (range 0–13)
using inheritance information derived from parental
data (figure 4). The difference between the number of
variants with and without parental data is primarily due
to heterozygous benign variants in dominant genes
inherited from unaffected parents (table 2). Probands
with unaffected parents had a mean of 0·9 (SD 0·9)
variants flagged, which increased to 3·2 (2·4) with one
affected parent and 7·4 (2·7) with two affected parents
(figure 4). In addition to SNVs and indels, a further 0·2
CNVs per proband were flagged.
All flagged variants were automatically annotated with
pathogenicity scores from two variant prioritisation
algorithms (SIFT23 and PolyPhen24) and compared against
the public Human Gene Mutation Database (HGMD) and
the Leiden Open Variation Database (LOVD), which
together contained only 14% of flagged variants. The
phenotypes recorded for each patient were compared
4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
Number of flagged variants (compound heterozygotes counted once)
Figure 3: Representation of phenotypic diversity in cohort
Our patient cohort represents children with a wide range of severe undiagnosed
developmental disorders ascertained clinically across the UK.
Proband only
Family trio
Filled = dominant genes; vertical = recessive genes; horizontal = X-linked
Neither (n=989)
One (n=121)
Parent affected status
Both (n=23)
Figure 4: Analysis of flagged variants in all 1133 children excluding (red) and including (blue) filtering on the
basis of parental genotypes and affected status (using the November 2013 version of DDG2P)
(A) Histogram of the number of flagged single nucleotide variants and insertion-deletions in 1133 children with and
without parental data. (B) Mean number of flagged variants per child with and without parental data for families where
neither, one, or both parents are affected by a developmental phenotype, subdivided by DDG2P genetic mechanism.
Note that compound heterozygous variants are counted once. Red=proband-only analysis. Blue=family-trio analysis
with parental genotype data. Filled=autosomal dominant DDG2P genes. Vertical stripes=autosomal recessive DDG2P
genes. Horizontal stripes=X-linked DDG2P genes. DDG2P=Developmental Disorders Genotype-to-Phenotype database.
against those previously published for patients with
similar mutations in the same gene, using primarily
DDG2P, PubMed, GeneReviews, and OMIM. If the
patient’s phenotype was deemed to be inconsistent with
the genetic change (on the basis of current knowledge of
the phenotypic spectrum of that gene), the variant was not
returned to the patient’s clinician. The manual review is
the most human-intensive step of the workflow, but was
essential for validation and improvement of the automated
filtering and prevention of likely non-pathogenic and
incidental findings from being reported. We expedited the
review of the variants in the most frequently observed
genes by requiring specific clinical features (eg, deafness)
that related to these genes to be noted in the patient.
www.thelancet.com Published online December 17, 2014 http://dx.doi.org/10.1016/S0140-6736(14)61705-0
Family-trio analysis
Autosomal dominant
Autosomal recessive (homozygotes)
Autosomal recessive (compound
Proband-only analysis
De novo*
X-linked dominant
X-linked recessive
11 447
Inherited variants in autosomal dominant DDG2P genes account for the main difference, in which only de novo variants
and those inherited from an affected parent are likely to be of clinical interest. Around 90% of flagged variants were
predicted to be missense point mutations. DDG2P=Developmental Disorders Genotype-to-Phenotype database.
*Before secondary validation by targeted Sanger sequencing. †Two or more likely pathogenic variants in different copies
of the same gene, counted once per compound variant.
Table 2: Total number of single nucleotide variants and insertion-deletions flagged by the clinical
reporting workflow in all 1133 probands (in the November, 2013 version of DDG2P) compared with the
number of variants that would have been flagged in the same probands in the absence of parental data
Reviewed (SNV,
Reported as
value of flag
Diagnostic yield
(%; n=1133)
been validated in an accredited diagnostic laboratory and
communicated to individual families. Additionally, we
found six likely pathogenic cases of uniparental disomy26
and five large mosaic chromosomal rearrangements
(unpublished data). We reported two separate genetic
findings in 17 individual cases in which both findings
might contribute to the phenotype.
With 328 likely diagnostic or strongly contributory
variants in 311 of 1133 children, our overall diagnostic rate
is 27%. Within DDG2P genes, de novo variants accounted
for 65% of our diagnoses across the cohort, and 92% of
those that were validated were regarded as pathogenic
(table 3). Although some genes were hit multiple times,
we found a diagnosis in only 146 (13%) individual DDG2P
genes, of which 92 were hit only once in this cohort
(appendix 2). We assessed the performance of five variant
prioritisation tools23,24,27–29 to help to interpret the
pathogenicity of missense variants (90% of flagged
variants), and found that PolyPhen and MutationTaster
discriminated equally well between reported and
non-reportable variants (appendix 1), but were nonetheless
unable to predict the likely diagnostic variants accurately.
Autosomal dominant
De novo
242 (193, 49)
528 (473, 55)
Autosomal recessive
De novo
6 (6, 0)
425 (424, 1)
De novo
41 (36, 5)
371 (360, 11)
83 (0, 83)
Uncertain inheritance
Chromosomal events
Uniparental disomy
See appendix 2 for details of individual genes and phenotype classes. The predictive value is the probability that a
flagged variant was reported as likely diagnostic (reported or reviewed), and the diagnostic yield is the contribution of
that type of variant to the overall diagnostic yield. Note that three pairs of siblings and two pairs of monozygotic twins
received the same diagnosis. Only 14% of reported variants were present in the public Human Gene Mutation Database
or Leiden Open Variation Database; 84% of flagged variants present in these databases were not reported, because
they did not appear to be relevant to the child’s phenotype. SNV=single nucleotide variant. CNV=copy number variant.
*17 probands received two contributory pathogenic variants.
Table 3: Likely diagnoses in the first 1133 families
Recent work has highlighted the need for caution in
interpretation of X-linked causes of intellectual disability,25
and we made the decision not to consider any inherited
missense variants on the X-chromosome (except in
patients with a family history of developmental disorders
or when the variant itself was present in either HGMD or
LOVD) because of the large number of variants but low
prior probability of causality for this class of variation.
After automated variant filtering, we manually reviewed
1696 candidate variants in 1133 family trios and reported
317 likely diagnostic SNVs, indels, and CNVs (table 3).
Many of these diagnostic variants have subsequently
We have developed and implemented a scalable workflow
within a large-scale rare-disease research study to allow
return of clinically pertinent genetic variants to clinicians
and research participants (panel). The workflow is
consistent with recently recommended guidelines for
investigating causality of sequence variants in human
disease,34,35 and we hope that it will act as a prototype for
the translation of diagnostic genome sequencing into the
clinic for a range of rare diseases. The semi-automated
system we have described achieved a diagnostic yield of
27% in previously investigated, yet undiagnosed, children
with developmental disorders caused by variants in
known genes across the genome (figure 5; appendix 1).
The system is amenable to an iterative approach to
reanalysis of patient data, and we expect that our
diagnostic yield will increase in the coming years as a
result of novel gene discovery (both within36 and outside
of the DDD study) and ongoing improvements to the
analysis algorithms and variant filtering rules.
De novo variants had by far the highest predictive
value and diagnostic yield in our cohort, highlighting the
value of having genotype data from both parents as well
as the child. Of our 215 likely de novo diagnoses, 41 were
CNVs and 174 were SNVs or indels, of which around half
(90/174) were novel missense variants and half (84/174)
were likely loss-of-function variants. Although we
attempted to validate almost all putative de novo SNVs
and indels in our cohort using targeted Sanger
sequencing—the diagnostic gold standard—this process
sometimes needed several attempts to optimise primer
design and achieve high-quality data. Given appropriate
quality thresholds and read depths in all three family
members, we believe that trio exome sequencing is
www.thelancet.com Published online December 17, 2014 http://dx.doi.org/10.1016/S0140-6736(14)61705-0
highly accurate for assessing de novo mutations, but
that targeted Sanger validation will remain important for
diagnostic confirmation and cascade testing.
For families in which neither parent is affected by the
same disorder, sequencing of parent–child trios rather
than individual probands offers around a ten-times
reduction in the number of candidate variants, thus
substantially increasing the speed and likelihood of
reaching an accurate diagnosis. By contrast, when one or
both parents are similarly affected, trio sequencing offers
only a three-times or 1·5-times reduction, respectively, and
might therefore be less informative. By contrast with our
trio-sequencing approach, de novo variants could instead
be identified in a stepwise fashion by exome sequencing of
the proband, then assay of possibly pathogenic variants in
both parents by targeted Sanger sequencing. However, in
view of the rapidly decreasing cost of exome and genome
sequencing (currently £1000–5000 per individual genome),
trio exome sequencing could offer a more rapid,
cost-effective, and scalable diagnostic method in addition
to providing increased usefulness in research.
Since most of our cohort had received at least
one genetic test before entering the study, introduction of
exome sequencing early in the diagnostic pathway could
substantially reduce costs and increase diagnostic yields
versus current clinical practice. Additionally, a small but
growing number of childhood developmental disorders
are amenable to existing therapeutic interventions, and
early treatment offers substantial benefits in preventing
irreversible clinical manifestations of the condition.
Currently, 82 reportable DDG2P genes are associated
with inborn errors of metabolism, which are causally
related to intellectual disability, and are potentially
amenable to therapy.37 To date, five DDD children have a
diagnostic variant in one of these treatable ID genes
(DHCR7, IVD, LMBRD1, MTR, and SLC2A1) and might
be suitable for either dietary restriction, supplementation,
or pharmacological intervention.
When developing our clinical feedback policy, our aim
was to maximise likely diagnoses while minimising
incidental findings, and we were conscious of the fact
that clinical teams have neither the resources nor the
remit to attempt to validate multiple variants of uncertain
significance in every patient. Like any medical test, the
variant filtering process necessitates a trade-off between
sensitivity and specificity, and any change to the analytical
pipeline will potentially alter this balance. With an
ever-expanding set of genes implicated in developmental
disorders, and in light of the fact that around 80% of our
flagged variants did not appear to be relevant to the
child’s developmental disorder, we hope to use
the manually curated results presented here to refine the
variant filtering rules further. Specifically, we expect to be
able to lower the frequency threshold to 0·1% for
dominantly inherited variants and, following an analysis
of variant prioritisation methods (appendix 1), to use
PolyPhen to exclude low-scoring inherited missense
Panel: Research in context
Systematic review
Trio exome sequencing is a highly successful research tool for new gene discovery.2 A
recent health technology assessment concluded that there is “scarce evidence supporting
the use of whole exome sequencing for etiologic diagnosis in patients with ID/DD”, and
warned that this technology presents “ethical dilemmas related to incidental findings in
the analysis of genetic material in these patients”.30 A systematic review was not done,
but we are aware of two smaller studies that have shown the likely usefulness of trio
exome sequencing for clinical diagnosis of children with severe intellectual disability,
including 51 patients from Germany or Switzerland31 and 100 patients from Nijmegen
(Netherlands).5 Clinical investigation of 410 rare disease patients from the University of
California32 achieved a 31% diagnostic rate for trio-based exome sequencing, and a large
single-centre study of 2000 rare disease patients from Baylor (USA)33 reported a
diagnostic rate of 25% using exome sequencing of the proband followed by targeted
follow-up testing in the parents.
Deciphering Developmental Disorders (DDD) is the first nationwide exome sequencing
study. It involves more than 1000 children with undiagnosed developmental disorders and
their parents, combining genome-wide data from high-resolution microarrays and trio
exome sequencing to maximise detection of potentially pathogenic variants. It achieved a
consistent diagnostic rate while demonstrating a scalable, collaborative model for
translational research. The informatics workflow developed by DDD has addressed one of
the key ethical challenges raised by massively parallel sequencing technologies and, by
using a clinically targeted analysis, shown that incidental findings can be minimised. The
DDD study will continue to recruit throughout the UK and Ireland until April, 2015, and
aims to reach 12 000 patients; we expect to continue to improve our analysis workflow
and increase the diagnostic rate higher than 30% as novel causal genes are discovered and
incorporated into diagnostic analyses, allowing existing patient data to be reinterpreted.
variants predicted to be benign. Although we plan to
automate more of the clinical reporting process, we
expect that some variants will always need expert
gene-specific clinical and scientific interpretation.
Because of the large number of rare variants in every
genome that are unrelated to disease, a genotype–
phenotype database (such as DDG2P) is crucial to allow
novel variants to be prioritised on the basis of current
knowledge of gene–disease associations and allelic
requirements. In principle this approach could be applied
to any medical specialism for the diagnosis of highly
penetrant genetic conditions. Although it is possible to use
a generic genotype-to-phenotype database for variant
filtering based on a broad phenotype (ie, developmental
disorders), detailed phenotypes are crucial for assignment
of likely pathogenicity to candidate variants. Fewer
candidate variants could be flagged by use of a smaller,
more targeted list, and restriction of the assay to only this
list of genes could potentially reduce the cost. We used the
DDG2P database to allow return of variants when the
patient’s phenotypes, developmental milestones, and
morphometric data were consistent with published reports
(this approach was not intended to allow association of
new phenotypes with known genes, which will need
further research). However, the value of whole genome or
exome sequencing as compared with targeted gene panels
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For more on existing
therapeutic interventions see
Figure 5: Genetic diagnoses associated with broad phenotype categories
Circos-style plot representing the genetic heterogeneity within developmental disorders, showing individual diagnoses in known Developmental Disorders
Genotype-to-Phenotype database genes, which links the genomic location of each gene with some key phenotypes in each child. Phenotypes are listed outside the
widest arc of the circle, chromosome numbers are indicated outside the smaller arc, and individual gene names are listed inside. Links are coloured by phenotype
group. See appendix 2 for details of the diagnoses. ID=intellectual disability. CHD=congenital heart defect. ASD=autism spectrum disorders. Deaf=hearing
impairment. Cleft=oral cleft. VI=visual impairment. MC=microcephalic dwarfism. PD=polydactyly.
lies primarily in the research potential for gene discovery,36
and the clinical usefulness of enabling future diagnoses to
be made in current patients from existing data. This
diagnostic benefit is already apparent within our cohort, in
which, on average, 20 new disease-implicated genes are
published and added to DDG2P per month, making
iterative analysis across the entire genomic dataset,
coupled with automated variant filtering and re-reviewing,
essential to maximise the diagnostic benefit.
An outstanding question remains regarding whether
researchers should actively search for so-called incidental
findings38 and thus undertake genomic screening of
medically relevant genomic variation as recommended
in standard clinical practice by the American College
of Medical Genetics and Genomics.39 We note that
searching for incidental findings in this manner is a
choice not a prerequisite of whole-genome sequencing,
because the analysis can be entirely diagnostically
www.thelancet.com Published online December 17, 2014 http://dx.doi.org/10.1016/S0140-6736(14)61705-0
targeted (as we have shown). At the outset of DDD, we
could not be confident that actively screening for
additional incidental findings unrelated to the child’s
developmental disorder would be in the best interests of
the patients and families within DDD, particularly in
view of the paucity of data regarding the true significance
of such variants ascertained in individuals with no
known previous risk of the cognate disease. Additionally,
such screening could potentially undermine established
clinical practice with respect to screening of children for
adult-onset conditions.
genotype-to-phenotype databases or specific variant
lists, the analytical procedure we have described could
be adapted to allow simultaneous opportunistic
screening for many conditions, if this were deemed to
be ethically appropriate and evaluation showed that
there was evidence of benefit to support this approach.8
However, the infrastructure needed to create and
support this workflow is considerable, and substantial
investment of staff time at all levels is needed to
ensure that it is accurate and robust. Hundreds of
individuals were involved in data entry, generation,
management, processing, analysis, interpretation,
and dissemination within DDD, including around
15 full-time staff with a dedicated laboratory and
priority access to a high-performance computing
cluster. Around 75 h were spent manually reviewing
the flagged variants in meetings that were attended by
between two and eight people including at least one
consultant clinical geneticist, and assessing the
clinical relevance of rare functional variants even in
well-known developmental disorder genes was often
very challenging. Interpretation of variants relating to
many other diseases in the absence of known
symptoms or family history would be even harder,
particularly in the absence of robust data concerning
population-ascertained penetrance, and additional
disease-specific expertise would no doubt be needed.
For these reasons, we chose to focus on identifying
pertinent findings within the DDD study to maximise
diagnostic yield and drive research into the underlying
causes of developmental disorders.
CFW drafted the paper. TWF, WDJ, JFM, MvK, HVF, DRF, MEH, and
CFW contributed to clinical review meetings. DRF and HVF created and
maintain DDG2P. JCB, SC, TWF, PJ, DAK, MvK, JFM, KIM, VP, AS,
and ART developed analysis packages, variant filtering algorithms, and
software to assist reporting. KA, DMB, TB, SG, NK, LEM, EP, and DR
were responsible for sample processing, DNA extraction, and array
comparative genomic hybridisation. PJ, MvK, RM, EP, and DR
undertook capillary sequence validation of de novo variants. APB, EB,
EAC, HVF, MEH, and GJS are responsible for the DECIPHER database
that allows recruitment and clinical reporting. AM and MP provided
ethical advice and contributions to the paper. JCB, NPC, DRF, HVF,
MEH, MP, and CFW are the management team. HVF is the clinical lead
and MEH is the scientific lead of the DDD study.
Declaration of interests
We declare no competing interests.
We thank all the staff at the regional genetics services in the UK and
Ireland (listed in appendix), the core sample processing and analysis
pipelines at the Wellcome Trust Sanger Institute, and the patients and
families in DDD. The DDD study presents independent research
commissioned by the Health Innovation Challenge Fund (grant number
HICF-1009-003), a parallel funding partnership between the Wellcome
Trust and the Department of Health, and the Wellcome Trust Sanger
Institute (grant number WT098051). The views expressed in this
publication are those of the author(s) and not necessarily those of the
Wellcome Trust or the Department of Health. The research team
acknowledges the support of the National Institute for Health Research,
through the Comprehensive Clinical Research Network.
Lupski JR, Reid JG, Gonzaga-Jauregui C, et al. Whole-genome
sequencing in a patient with Charcot-Marie-Tooth neuropathy.
N Engl J Med 2010; 362: 1181–91.
Bamshad MJ, Ng SB, Bigham AW, et al. Exome sequencing as a tool
for mendelian disease gene discovery. Nat Rev Genet 2011; 12: 745–55.
Yang Y, Muzny DM, Reid JG, et al. Clinical whole-exome
sequencing for the diagnosis of mendelian disorders. N Engl J Med
2013; 369: 1502–11.
Worthey EA, Mayer AN, Syverson GD, et al. Making a definitive
diagnosis: successful clinical application of whole exome
sequencing in a child with intractable inflammatory bowel disease.
Genet Med 2011; 13: 255–62.
de Ligt J, Willemsen MH, van Bon BWM, et al. Diagnostic exome
sequencing in persons with severe intellectual disability.
N Engl J Med 2012; 367: 1921–29.
Wolf SM, Crock BN, Van Ness B, et al. Managing incidental findings
and research results in genomic research involving biobanks and
archived data sets. Genet Med 2012; 14: 361–84.
Kohane IS, Masys DR, Altman RB. The incidentalome. JAMA 2006;
296: 212–15.
Wright CF, Middleton A, Burton H, et al. Policy challenges of
clinical genome sequencing. BMJ 2013; 347: f6845.
Berg JS, Khoury MJ, Evans JP. Deploying whole genome
sequencing in clinical practice and public health: meeting the
challenge one bin at a time. Genet Med 2011; 13: 499–504.
10 Dorschner MO, Amendola LM, Turner EH, et al. Actionable,
pathogenic incidental findings in 1000 participants’ exomes.
Am J Hum Genet 2013; 93: 631–40.
11 Firth HV, Wright CF, the DDD Study. The Deciphering
Developmental Disorders (DDD) study. Dev Med Child Neurol 2011;
53: 702–03.
12 Sagoo GS, Butterworth AS, Sanderson S, Shaw-Smith C,
Higgins JPT, Burton H. Array CGH in patients with learning
disability (mental retardation) and congenital anomalies: updated
systematic review and meta-analysis of 19 studies and
13 926 subjects. Genet Med 2009; 11: 139–46.
13 O’Roak BJ, Deriziotis P, Lee C, et al. Exome sequencing in sporadic
autism spectrum disorders identifies severe de novo mutations.
Nat Genet 2011; 43: 585–89.
14 Vissers LELM, de Ligt J, Gilissen C, et al. A de novo paradigm for
mental retardation. Nat Genet 2010; 42: 1109–12.
15 Topper S, Ober C, Das S. Exome sequencing and the genetics of
intellectual disability. Clin Genet 2011; 80: 117–26.
16 Middleton A, Parker M, Wright CF, Bragin E, Hurles ME, on behalf
of the DDD Study. Empirical research on the ethics of genomic
research. Am J Med Genet A 2013; 161: 2099–101.
17 Middleton A, Morley KI, Bragin E, et al, on behalf of the Deciphering
Developmental Disorders Study. No expectation to share incidental
findings in genomic research. Lancet 2014; published online Dec 17.
18 Robinson WP. Mechanisms leading to uniparental disomy and
their clinical consequences. BioEssays 2000; 22: 452–59.
19 Robinson PN, Mundlos S. The human phenotype ontology.
Clin Genet 2010; 77: 525–34.
20 Bragin E, Chatzimichali EA, Wright CF, et al. DECIPHER: database
for the interpretation of phenotype-linked plausibly pathogenic
sequence and copy-number variation. Nucleic Acids Res 2014;
42 (Database issue): D993–1000.
www.thelancet.com Published online December 17, 2014 http://dx.doi.org/10.1016/S0140-6736(14)61705-0
Ramu A, Noordam MJ, Schwartz RS, et al. DeNovoGear: de novo
indel and point mutation discovery and phasing. Nat Meth 2013;
10: 985–87.
McLaren W, Pritchard B, Rios D, Chen Y, Flicek P, Cunningham F.
Deriving the consequences of genomic variants with the Ensembl
API and SNP effect predictor. Bioinformatics 2010; 26: 2069–70.
Kumar P, Henikoff S, Ng PC. Predicting the effects of coding
non-synonymous variants on protein function using the SIFT
algorithm. Nat Protoc 2009; 4: 1073–81.
Adzhubei IA, Schmidt S, Peshkin L, et al. A method and server for
predicting damaging missense mutations. Nat Methods 2010;
7: 248–49.
Piton A, Redin C, Mandel J-L. XLID-causing mutations and
associated genes challenged in light of data from large-scale human
exome sequencing. Am J Hum Genet 2013; 93: 368–83.
King DA, Fitzgerald TW, Miller R, et al. A novel method for detecting
uniparental disomy from trio genotypes identifies a significant
excess in children with developmental disorders. Genome Res 2014;
24: 673–87.
Kircher M, Witten DM, Jain P, O’Roak BJ, Cooper GM, Shendure J.
A general framework for estimating the relative pathogenicity of
human genetic variants. Nat Genet 2014; 46: 310–15.
Petrovski S, Wang Q, Heinzen EL, Allen AS, Goldstein DB. Genic
intolerance to functional variation and the interpretation of
personal genomes. PLoS Genet 2013; 9: e1003709.
Schwarz JM, Rodelsperger C, Schuelke M, Seelow D.
MutationTaster evaluates disease-causing potential of sequence
alterations. Nat Methods 2010; 7: 575–76.
Pichon Riviere A, Augustovski F, Garcia Marti S, et al. Whole
exome sequencing for patients with intellectual disability/mental
retardation or ASD. Informe de Respuesta Rápida 320. Buenos
Aires: Institute for Clinical Effectiveness and Health Policy, 2013.
Rauch A, Wieczorek D, Graf E, et al. Range of genetic mutations
associated with severe non-syndromic sporadic intellectual
disability: an exome sequencing study. Lancet 2012; 380: 1674–82.
Lee H, Deignan JL, Dorrani N, et al. Clinical exome sequencing for
genetic identification of rare mendelian disorders. JAMA 2014;
312: 1880–87.
Yang Y, Muzny DM, Xia F, et al. Molecular findings among patients
referred for clinical whole-exome sequencing. JAMA 2014;
312: 1870–79.
Koboldt DC, Larson DE, Sullivan LS, et al. Exome-based mapping
and variant prioritization for inherited mendelian disorders.
Am J Hum Genet 2014; 94: 373–84.
MacArthur DG, Manolio TA, Dimmock DP, et al. Guidelines for
investigating causality of sequence variants in human disease.
Nature 2014; 508: 469–76.
DDD Study. Large-scale discovery of novel genetic causes of
developmental disorders. Nature (in press).
van Karnebeek CDM, Stockler S. Treatable inborn errors of
metabolism causing intellectual disability: a systematic literature
review. Mol Genet Metab 2012; 105: 368–81.
Gliwa C, Berkman BE. Do researchers have an obligation to actively
look for genetic incidental findings? Am J Bioeth 2013; 13: 32–42.
Green RC, Berg JS, Grody WW, et al. ACMG recommendations for
reporting of incidental findings in clinical exome and genome
sequencing. Genet Med 2013; 15: 565–74.
www.thelancet.com Published online December 17, 2014 http://dx.doi.org/10.1016/S0140-6736(14)61705-0